Chest pain, r/o Acute Coronary Syndrome (ACS)

Hospital A/P, Adults

Definition of ACS, reviewed.
History & Physical, see above.
Differential diagnosis of chest pain, reviewed.
Risk Factors for CAD from H&P are:_____________
Pretest Probability of CAD: High / Intermediate / Low / Very low
HEART score:_______ (out performs TIMI score with low-risk categories).
TIMI score:________ (helps in choosing early invasive strategy vs. medical therapy)
ACS treatment algorithm reviewed
Indications for early invasive strategy vs. conservative strategy with medical therapy reviewed.
Labs/Imaging: Will order/review the following:
–ECG (on presentation), CXR, Serial Troponin I.
–CBC, CMP, BNP, etc
–HbA1c, Fasting Lipid Panel, TSH (to risk stratify or assess for CV risk factors)
-Admit to telemetry; cardiac monitor.
-F/u pending labs and images.
-Repeat ECG (in the am)
–Morphine sulfate 2 to 4 mg IV PRN for severe pain. May repeat dose of 2 to 8 mg IV at 5 to 15-minute intervals.
–Oxygen only if oxygen saturation< 90%, respiratory distress, or high-risk hypoxemia. Keep O2 sats > 92%
–Nitroglycerin (NTG) 0.4 mg SL q5min PRN chest pain. Max: 3 doses within 15 minutes as BP allows. Consider IV NTG in pts w/ persistent pain after three sublingual nitroglycerin tablets, HTN, or HF. NTG or nitrates are contraindicated in patients who have taken a phosphodiesterase inhibitor for erectile dysfunction within the previous 24 hours.
–Aspirin and P2Y12. The first tab is 162-325 (chew), then 81mg QD after that.  “In the absence of an absolute contraindication, antiplatelet therapy with aspirin and a platelet P2Y12 receptor blocker is indicated in all patients with a non-ST elevation ACS”
–Beta-blocker. Metoprolol tartrate 25-50 mg PO q6-12h (titrate to keep HR 50-60) IF no signs of HF, not at high risk for HF, and no signs of hemodynamic compromise, bradycardia, or severe reactive airway disease. Don’t start BB acutely if the patient has signs of HF.
–ACE. Lisinopril 2.5 to 5 mg per day, titrate up to 10 mg as tolerated. Watch BP. May wait to see BB work if concerned about BP or start a low dose.
–Statin. High-intensity statin – Atorvastatin 40-80 mg PO QHS or 20-40 mg of Rosuvastatin PO QHS.
–Heparin or other anticoagulant- Will start anticoagulation. All non-ST elevation ACS patients need to be on anticoagulant therapy ASAP after diagnosis.
–Stress test: Indicated in ACS pts with intermediate pre-test probability of CAD. If the pre-test probability for CAD is high, skip stress test and go for angiography (PCI). Cardiology to decide. Options: Lexiscan stress, Treadmill stress test
–Transthoracic Echocardiography (TTE) –  Look for new wall motion abnormality.
-Coronary Angiography -This is the gold standard and allows for treatment (stent placement) at the same time if the patient needs it. Cardiology to decide.
-Cardiology consulted.
-D/C all NSAIDs (except for Asprin) b/c of an increased risk of cardiovascular events.

 

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HF= Heart failure;
SL= Sublingual

Important Links

DAPT = Dual antiplatelet therapy.

The HEART score outperforms TIMI and has better discrimination than TIMI.

When is CT angiography, or rest perfusion imaging recommended?

***What is the most common symptom of cardiac ischemia in elderly patients? Dyspnea!
Elderly people, diabetics, females, and patients with a hx of stroke or HF are at increased risk for atypical presentation

Ischemic Heart Disease

#1 cause of death in the USA
Stable angina: activity → chest pain (CP), relieved by rest, NTG
Unstable angina: CP at rest
CP, dyspnea, diaphoresis, nausea, hiccups, radiation to shoulder/jaw/back
Earliest ECG sign of MI: hyperacute T waves
Up to 50% of ECGs are negative or nonspecific
Highest S/S: troponin I

 

“Evidence-based guidelines for the treatment of patients with acute coronary syndrome support several medications in the subacute period. Dual antiplatelet therapy, such as clopidogrel combined with aspirin, has been shown to reduce cardiovascular mortality (SOR B). ACE inhibitors and statins should be initiated immediately after a myocardial infarction and continued indefinitely to reduce mortality and the risk of repeat infarction (SOR A). Beta-Blockers have been shown to improve mortality in patients with a left ventricular ejection fraction <40% (SOR A). Nitroglycerin is often used to manage angina but has no demonstrated mortality benefit.” ABFM

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Sample Case

Question: In a patient presenting with unstable angina, what findings denote the highest risk for death or myocardial infarction?

See the table in the following AAFP article. http://www.aafp.org/afp/2013/1001/p469.html

NSAIDs in patients with MI

The safest NSAIDs for patients with a previous history of MI = Naproxen (Aleve)

“All oral NSAIDs  increase  the risk  of myocardial infarction, with the exception of naproxen. Cardiac risks are greater in older patients, those with a history of cardiac events, and with higher dosages.” AFP 2013

 

 

References

Am Fam Physician. 2017 Feb 1;95(3):170-177. http://www.aafp.org/afp/2017/0201/p170.html

https://www.uptodate.com/contents/overview-of-the-acute-management-of-non-st-elevation-acute-coronary-syndromes

Am Fam Physician. 2017 Feb 15;95(4):232-240. http://www.aafp.org/afp/2017/0215/p232.html

Am Fam Physician 2013;87(5):354-356.

http://www.aafp.org/afp/2013/1001/p469.html

https://www.ncbi.nlm.nih.gov/pubmed/26881812

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